Hemorrage in oral surgery

Hemorrage in oral surgery - Diagnosis and Management of...

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Unformatted text preview: Diagnosis and Management of Hemorrhage in Oral Surgery Division of Oral and Maxillofacial Surgery Division College of Dentistry College King Saud University King What is meant by Hemorrhage ? Prolonged or uncontrolled bleeding is often referred to as hemorrhage. referred The amount of blood lost as a result of hemorrhage can range from minimal to minimal significant quantities. quantities. Hemorrhage in Surgery Hemorrhage can occur to a greater or lesser degree during all surgical procedures and it’s management depends upon whether the patient is hematologically normal or suffers from some hematologically disturbance in the normal clotting mechanism. disturbance Hemorrhage in Oral Surgery Hemorrhage in Oral Surgery s The overwhelming majority of patients who The undergo oral surgical procedures are those who have normal haemostatic mechanism. have s Therefore, significant or major hemorrhages are Therefore, not that common in oral surgery except in patients who have a bleeding / clotting disorder or those who are on anticoagulants. who Hemorrhage in Oral Surgery However, uncontrolled and persistent bleeding can occur in some healthy patients after dental extraction. extraction. Therefore, it is still important to achieve proper hemostasis in all patients during oral surgical procedures, so as to prevent excessive postprocedures, operative blood loss. Normal Mechanism of Hemostasis s Hemostasis is a complicated process. Hemostasis s It involves a number of events It Hemostasis - Normal Mechanism s 1. VASCULAR PHASE s 2. PLATELET PHASE s 3. COAGULATION PHASE VASCULAR PHASE When a blood vessel is damaged, vasoconstriction results. vasoconstriction PLATELET PHASE Platelets adhere to the damaged surface and and form a temporary plug. COAGULATION PHASE Through two separate pathways, the Intrinsic and Extrinsic, the conversion of fibrinogen to fibrin is complete. Fibrin tightly binds the platelets to form a clot THE CLOTTING MECHANISM INTRINSIC EXTRINSIC Collagen Tissue Thromboplastin XII XI IX VIII VII X V PROTHROMBIN (II) FIBRINOGEN (I) THROMBIN (III) FIBRIN HEMOSTASIS DEPENDENT UPON: x Vessel Wall Integrity Vessel y Adequate Numbers of Platelets Adequate z Proper Functioning Platelets Proper { Adequate Levels of Clotting Factors Adequate | Proper Function of Fibrinolytic Pathway Proper Hemorrhage in Oral Surgery s Hemorrhage following Oral Surgical procedures Hemorrhage can occur due to local or systemic causes. local systemic s In healthy patients the postoperative bleeding is In mainly due to local causes. mainly Local causes of hemorrhage in oral surgery Local causes of hemorrhage originate in either soft tissue or bone. soft bone. Local causes of hemorrhage in oral surgery – Soft tissue bleeding s Soft tissue bleeding is either arterial, venous, or Soft arterial venous or capillary in nature. capillary Local causes - Soft tissue bleeding in oral surgery s Arterial bleeding is bright red and spurting in nature. s Arteries in the soft tissues at risk during oral surgical Arteries procedures are the lies posterior portion of hard palate) greater palatine artery and the buccal artery (lies lateral to greater buccal the retromolar pad) the Local causes - Soft tissue bleeding in oral surgery Venous blood is dark red in color and flows steadily and heavily especially if the vein is large. steadily Capillary bleeding is bright red in color and is more of a minimal ooze. more Local causes – Osseous (Bony) bleeding in oral surgery Troublesome bone bleeding originates either from nutrient canals in the alveolar region, central vessels, such as the inferior alveolar artery, or inferior or from central vascular lesions (Hemangioma or Vascular malformation) Vascular Systemic causes of hemorrhage in oral surgery s Some patients with heriditary conditions such as Some hemophilia, Von Willebrand’s disease are susceptible for hemorrhage following oral surgical procedures. hemorrhage s Patients with thrombocytopenia (decreased platelet Patients count) , Leukemia e.t.c., are also at risk of prolonged bleeding after surgery. bleeding s Patients with uncontrolled hypertension. Systemic causes of hemorrhage in oral surgery s Patients with H/O prosthetic heart valve replacement, Patients Stroke (Cerebrovascular accident) e.t.c., take oral Stroke e.t.c., anticoagulants like Aspirin or Warfarin to prevent the anticoagulants occurrence of a thromboembolic episode. s These patients are also at risk of prolonged severe These bleeding during and after an oral surgical procedure. bleeding Types of Hemorrhage - Primary Hemorrhage This occurs during the surgery, as a result of injury like cutting or laceration of the artery or bleeding from bone. bone. This also occurs when surgery is done in an infected area with a lot of granulation tissue. area It can also occur after a very short period of time immediately after surgery. This type of bleeding is really normal and can be controlled easily. controlled Types of Hemorrhage - Intermediate / Reactionary Hemorrhage This type of bleeding occurs within a few hours after surgery. surgery This type of bleeding occurs as a result of failure of coagulation to occur (as in patients with systemic bleeding problems or those on anticoagulants) bleeding Patients who have unknowingly disturbed / dislodged the clot are also prone for this type of bleeding. clot Types of Hemorrhage - Secondary Hemorrhage This occurs after 7 to 10 days after surgery. This is to mainly due to partial division of blood vessel in combination with infection of the wound (Like patient’s who undergo radical neck dissection e.t.c.,). who This type of bleeding is not very frequently encountered after oral surgery procedures. after Management of Primary Hemorrhage in Normal patients The management of bleeding during surgery (Primary bleeding) can be achieved by the following means, bleeding) (i) (ii) (iii) (iv) (v) Securing / ligation of blood vessels with silk sutures. Use of pressure swab to achieve hemostasis. Use of electrocautery to achieve hemostasis. Use of hemostatic agents like bone wax, surgicel,e.t.c., Hypotensive anaesthesia (G.A) and use of Hypotensive vasoconstrictors in L.A. vasoconstrictors Local Measures ( Synthetic Materials) s There are several materials that are commercially There available that are used locally for achieving adequate hemostasis. adequate Local Measures: Surgicel (Oxidised Regenerated Cellulose) Local measures: Gelfoam with activated thrombin Local Measures: Avitene (Microfibrillar Collagen) Local Measures: Etik Collagen (Packed collagen) Local Measures: Tranexamic acid 5% Local Measures: Tranexamic acid 5% in Syringe Local Measures: Irrigation of wound with Tranexamic acid Local Measures: Suturing the wound Local Measures: Pressure with oral packs Management of Intermediate Hemorrhage in Normal patients s The management of bleeding that occurs immediately The after surgery (Reactionary bleeding) involves proper examination of the surgical wound to identify the site of bleeding (i.e ) from bone or soft tissue. of (i) If bleeding is from bone then the hemostatic agents like If bone wax or gelfoam is usually used. bone (ii) If bleeding is from soft tissues then, ligation / If cauterization of blood vessels along with the use of hemostatic agents like surgicel and suturing of the wound is carried out. wound Management of Secondary Hemorrhage in Normal patients s The management of this type of bleeding that occurs a The few days after surgery involves the removal of any debris from the wound surface that promotes the infection of the wound. wound s Identify the source of bleeding and treat as would be Identify done in a patient with secondary bleeding. done s Surgical stents can be placed over extraction sockets for Surgical stabilization of clot and prevention of wound contamination. contamination. Management of Hemorrhage in patients with bleeding disorders / and those on anticoagulant therapy s The usual protocol involved in the treatment of this group The of patients consists of pre-operative blood investigations and preoperative correction of the underlying deficiency (Replacement of Clotting factors / platelets) if any in these patients. these s Subsequently, after this appropriate local measures are used to decrease the chances of post-operative bleeding. used LABORATORY EVALUATION PLATELET COUNT s BLEEDING TIME (BT) s PROTHROMBIN TIME (PT) s PARTIAL THROMBOPLASTIN TIME (PTT) s THROMBIN TIME (TT) s PLATELET COUNT Ë NORMAL NORMAL 100,000 - 400,000 CELLS/MM 3 < 100,000 100,000 Thrombocytopenia Thrombocytopenia 50,000 - 100,000 Mild Thrombocytopenia < 50,000 50,000 Severe Thrombocytopenia Severe BLEEDING TIME q PROVIDES ASSESSMENT OF PLATELET COUNT AND FUNCTION NORMAL VALUE 2-8 MINUTES 2-8 PROTHROMBIN TIME q Measures Effectiveness of the Extrinsic Pathway NORMAL VALUE 10-15 SECS 10-15 PARTIAL THROMBOPLASTIN TIME q Measures Effectiveness of the Intrinsic Measures Pathway Pathway NORMAL VALUE 25-40 SECS 25-40 THROMBIN TIME q Time for Thrombin To Convert Fibrinogen Fibrin q A Measure of Fibrinolytic Pathway NORMAL VALUE 9-13 SECS 9-13 Management of Hemorrhage in patients with uncontrolled hypertension. s This group of patients need appropriate medical This consultation for initiation of medical treatment to decrease their Blood Pressure. decrease s Thus once their B.P is controlled, then the bleeding Thus decreases and with local measures the hemorrhage is controlled. controlled. ...
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